Basic Information
| Provider Information | |||||||||
| NPI: | 1467970616 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RENDON | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | PRIMITIVO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8524 W GAGE BLVD | ||||||||
| Address2: | BLDG A1 BOX 319 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993368241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
| FaxNumber: | 5093969661 | ||||||||
| Practice Location | |||||||||
| Address1: | 12709 E MIRABEAU PKWY | ||||||||
| Address2: | BLDG A STE 200 | ||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
| FaxNumber: | 5095910070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA60932463 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA60932463 | 01 | WA | STATE LICENSE | OTHER | OA60965163 | 01 | WA | STATE LICENSE | OTHER |